OPERATIONS Flashcards

Question

MEDIASTINAL SURGERY

Answer 1

Either Diagnostic/Therapeutic. Usually access via suprasternal notch - Airway obstruction - Pleura brached (ok as no leak from lung) - Neck Extension - Bleeding

Answer 2

introduction of a substance into the pleural space (usually talc) to create inflammatory adhesions. DLT + OLV +/- Regional or PCA No NSAIDs/Dex

Answer 3

Pneumonectomy is excision of a whole lung for lung cancer. (Mortality 6%) ``` Big Case IAL + CVC TE DLT OLV Caution Fluid - Vasopressors ICU post NO SUCTION TO DRAIN ``` ``` Complications Bleeding ALI/Resp Failure Infection AF! ```

Answer 4

PREOP Identify and evaluate comorbidities Optimise condition Make informed decisions for best management INDUCTION IAL/CVC/5 lead ECG TE -avoid haemodynamic instability @ induction,laryngoscopy, intubation, cross clamp Use epidural/remi ? volatile - preconidtioning - epidural - vasodilation HEPARIN CROSS CLAMP - ON - AFTERLOAD INCREASE - MYOCARDIAL ISCHAEMIA CROSS CLAMP OFF = PROFOUND HYPOTENSION - ischaemia BLOOD LOSS - CELL SALVAGE ``` COMPLICATIONS SURGICAL - ischaemic limb - embolisation haemorrhage GIT ischaemia (IMA sacrificed) Infections ``` MEDICAL Myo Ischaemia AKI Resp Failure

Answer 5

``` HIGH MORTALITY CLINICAL JUDGEMENT > RISK INDICES OPEN VS EVAR RESUS - Limit aim SBP 70 MTP/ CEll SALVAGE ``` PREINDUCTION IAL (dont delay surgery), CVC (after clmap) Blood products, rapid infuser Drugs - pressor + inotrope INDUCTION RSI - KEtamine Anticipate collapse as abdomen opens Anaesthetic requirement low until cross clamp HAEMORRHAGE COMMON CONTROLLED CROSS CLAMP RELEASE - acidosis, potassium ICU Intubated

Answer 6

Occlusion balloon may be deployed in aorta to provide stability. ``` PERIOP Complications Haemmorhage Ischaemic Limb - embolisation Ischaemic GIT/Spinal Cord Intra abdominal compartment syndrome ``` ``` MEDICAL MI AKI Resp Failure Coagulopathy ``` ``` CONTRAST LOAD - AKI CONVERSION TO OPEN REGIONAL/GA HEPARIN HYBRID OT BLEEDING SHEATH PORTS ``` POST OP ICU WATCH AKI COMPLICATIONS

Answer 7

Occlusion balloon may be deployed in aorta to provide stability. ``` PERIOP Complications Haemmorhage Ischaemic Limb - embolisation Ischaemic GIT/Spinal Cord Intra abdominal compartment syndrome ``` ``` MEDICAL MI AKI Resp Failure Coagulopathy ``` ``` CONTRAST LOAD - AKI CONVERSION TO OPEN REGIONAL/GA HEPARIN HYBRID OT BLEEDING SHEATH PORTS ``` POST OP ICU WATCH AKI COMPLICATIONS ``` SURGICAL ENDOLEAK MALDEPLOYMENT STENT GRAFT THROMBOSIS/MIGRATION AORTIC RUPTURE DISTAL EMBOLISATION CONVERSION OPEN ``` ``` MEDICAL AKI; contrast; ischaemia/obstruction MI POst implantation syndrome - fever , CRP, DIC shock, self limiting SEPSIS ```

Answer 8

decreased CBF and intiating platelet or clot embolism symptomatic - >70% with 2 weeks symptoms cross clamp - risk of cerebral hypoperfusion and ischaemia (CBF dependant on COW) - a shunt may be placed. Shunts can kink, damage arterial wall, embolic complications. BP Targets @ baseline or 20% above Stimulation = laryngoscopy, cross clamp, sugical stimulus, carotid sinus manipulation. extubation. ``` GA ADVANTAGES • Provides more controlled operating conditions. • Avoids need for patient compliance. • Reduces CMRO2. • Reduces catecholamine release and stress response of surgery. • Allows greater cardiovascular control/ pharmacological manipulation. ``` GA DISADVANTAGES • Reduces CBF. • May lead to more frequent, unnecessary shunt use with associated complications. • Risks failure to detect cerebral ischaemia post– cross-clamp insertion. • Haemodynamic fluctuations associated with induction, laryngoscopy and extubation LA ADVANTAGES • Allows direct cerebral function monitoring • Reduces unnecessary shunt insertion • Avoids the haemodynamic instability associated with induction, laryngoscopy, intubation and extubation • Preserves cardiovascular and cerebrovascular autoregulation LA DISADVANTAGES • Poor access to airway • Requires patient compliance • May be claustrophobic, uncomfortable and stressful for patient • May provide inadequate analgesia requiring supplementation, sedation or general anaesthesia • Conversion to GA is likely to be hurried and uncontrolled COMPLICATIONS Haemtoma and oedema - re-exploration Stroke Nerve damage - hypoglossal > recurrent > superior >margical mandibular nerve Medical MI Labile BP Post op hypertension may occur possible due to baroreceptor dysfunction . Marked hypertension may injure myocardium and lead to hyperperfusion symdrome. Hypotension also possible. HYPERPERFUSION SYndrome = sig increase in CBF following removal of stenosis // headache htn seizures, cerebral oedema SAH ICH - emergency - HTN - ICU

Answer 9

ELECTIVE VS EMERGECY Critical Ischaemia within 6 hrs Start as embolectomy - balloon- stent -- bypass Blood loss - minimal (revas) Anticoagulaton - Heparin ``` SURGICAL ongoing ischaemia gangrene to sepsis repeat surgery poor wound healing reperfusion injury - K AKI Compartment syndrome ``` ``` MEDICAL MI RHABDO AKI REsp Failure ```

Answer 10

Open eye with full stomach situation • Delay before surgery for penetrating eye injury may increase risk of loss of contents of globe and increase risk of infection • Associated trauma, particularly of head and neck • Danger of extrusion of globe contents at induction ``` • Assessment of associated injuries as resuscitation and urgent surgery may be required for non-ophthalmic problems • If surgery is within 24 h of injury, treat as a full stomach • Assess airway for rapid sequence induction • Assess and optimise coexisting medical conditions if time allows ``` ``` Give alfentanil 0.02 mg/kg, propofol 3 mg/kg, rocuronium 0.6 mg/kg and apply cricoid pressure. Intubation can be performed at 60 seconds without coughing ``` ``` Antiemetic prophylaxis. • Analgesia with NSAID or opiate. EMERGENCE AND RECOVERY • Antagonism of neuromuscular block • Extubate awake. ```

Answer 11

Pateint - Child vs Adult - OSA, congenital , Malignancy, Smoker, RHF ETT Neck Extension Extubatoin Awake Post op monitoring TONSIL BLEED UPPER AIRWAY OBSTRUCTION BLOOD LOSS NOT MEASURABLE ASPIRATION RISK ``` DOUBLE SUCTION RESUS - CROSSMATCH SMALLER TUBE OROGASTRIC EMPTY STOMACH RSI ```

Answer 12

ELECTIVE VS EMERGENCY LA VS GA Reason - acute/chronic upper airway obs, planned for surgery, aspiration risk PRE OP - BASELINE / IMAGING / AIRWAY PLANNING NEED PLANSSSS COMMUNICATION - tube /retraction/change circuit SURGEONS SCRUBBED

Answer 13

AIRWAY ASSESSMENT - tracheal deviation narrowing - mediastinal extension - SVC CHECK EUTHYROID CHECK MEDICATIONS - Carbimazole = inhibits iodination of tyrosyl residues in thyroglobulin Propylthiouracil = carbimazole + decreases preipheral de iodination of T4->T3 BBlock - control CVS symptoms , propranolol decreases T4-T3 conversion Iodine - 7-10 days preop - reduction thyroid vascularity CHECK CARDIAC FUNCTION MAY BE PART OF MEN SYNDROME OT AIRWAY - NIM - muscle relaxants Cord check at end POST OP HYPOCALCAEMIA - check Ca - Parathyroid RLN Palsy Haematoma - RARE COMPLICATIONS Tracheomalacia Pneumothorax ( retrosternal resection_ Thyroid Storm - ICU

Answer 14

PREOP Assessment extent Smoke inhalation Resuscitation ``` Theatre Preperation Warm OT Access Multiple Operators Blood Loss / Fluid Catabolic No Sux Analgesia ```